Information Collection

Request for Certification of Foreign National Adult Victims of Human Trafficking

IC 215217 under ICR 202201-0970-008 · OMB 0970-0454.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0454 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Request for Certification of Foreign National Adult Victims of Human Trafficking	Form
Attachment B_Shepherd RFC Webform Instructions.pdf	Instruction
Attachment B_Shepherd RFC Webform Instructions.pdf	Instruction
1 Request for HHS Certification of Foreign National Adult RFC SSA_1.21.22.docx	Form
1 Request for HHS Certification of Foreign National Adult Attachment A_Proposed RFC_3.31.22_Clean.pdf	Form

IC Title:

Request for Certification of Foreign National Adult Victims of Human Trafficking

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Request for HHS Certification of Foreign National Adult Victims of Human Trafficking	Attachment A_Proposed RFC_3.31.22_Clean.pdf		Yes	Yes	Fillable Printable
Instruction			Attachment B_Shepherd RFC Webform Instructions.pdf		Yes	Yes	Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	433	-367	800
Annual IC Time Burden (Hours)	433	33	400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.